Chronic Invasive Fungal Sinusitis Causing Pathologic LeFort I Fracture in an Immunocompetent Patient

We present the case of a 77-year-old immunocompetent woman with history of chronic rhinosinusitis who presented with pathologic LeFort I fracture after a forceful sternutation. The patient noted mild maxillary tooth discomfort following the incident and was placed on oral antibiotics, antifungals, and soft diet that failed to resolve her tooth discomfort over several months. Imaging revealed diffuse sinus opacification and LeFort type I complex fracture involving the maxilla, pterygoid plates, clivus, and right nasal bridge. There was no evidence of soft tissue swelling. The patient underwent endoscopic debridement of her sinuses, which revealed mucosal dehiscence and otherwise bleeding tissue. Frozen section was negative for fungal invasion. However, final anatomic pathology indicated necrotic bone fragments with invasive fungal hyphen. Cultures demonstrated enterococcus, burkholderia cepacia, serratia, and diphtheroid species. Fungal species were not identified from fungal cultures. The patient was started on intravenous antibiotics and antifungals for several months without significant improvement in bone healing on interval imaging. In spite of this, the stability of her palate improved on clinical examination. Chronic rhinosinusitis is associated with orbital and cranial soft tissue infectious complications but to our knowledge, this is the first report of pathologic facial fracture because of chronic invasive fungal and bacterial rhinosinusitis.